The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
The 24-hour oral intake is 600 ml greater than the total output.
The patient's temperature is 100.3" F 137.9" C).
The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating
The patient's calf is swollen, warm, and painful.
The Correct Answer is D
These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.
DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The signs or symptoms the nurse would observe in a 4-year-old client experiencing a recurrence of minimal change nephrotic syndrome (MCNS) include:
- MCNS is characterized by increased glomerular permeability, leading to the loss of protein, particularly albumin, in the urine. Proteinuria is a hallmark feature of MCNS and is usually detected through urine testing.
- Due to the excessive loss of protein in the urine, particularly albumin, the client with MCNS may have low levels of albumin in the blood. Hypoalbuminemia can result in various complications, such as edema formation and impaired immune function. However this is not a sign or symptom.
- Edema is a common symptom of MCNS and typically presents as swelling in the face, around the eyes, and in the extremities. This is a result of the fluid shifts and fluid retention caused by the altered glomerular function and hypoalbuminemia.
Hypocalcemia and ketones in the urine are not typically associated with MCNS. Hypocalcemia can occur in some types of kidney disease, but it is not a characteristic feature of MCNS. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or inadequate carbohydrate intake.
Correct Answer is D
Explanation
Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.
Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.
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